How to plan and deliver amazing nursing care to your GI patients [Case Study]
There’s an age-old joke in medicine - that all we do is deal with poo!
And I’m not going to do much to dispel that myth today - BUT the reality is, we do see GI patients commonly.
And whilst many of these cases are quite simple to manage, we can see some really challenging GI cases, who require intensive treatment and nursing.
Last month, I introduced my VIP list to Bea - a collie with chronic diarrhoea, vomiting, and regurgitation. She had a diagnosis of suspected protein-losing enteropathy, and I had them plan her nursing care.
So let’s look at Bea’s case, and explore the skills we can use to nurse her in the hospital.
Meet Bea
Bea is a 6-year-old FN Border Collie.
She presents to you with an at least 4 week history of progressive diarrhoea (initially pasty in consistency, progressing to profuse watery diarrhoea), one episode of vomiting, regurgitation, and weight loss.
Examination
You examine Bea and find that she is::
Bright and alert
Well hydrated with pink and moist MMs
Normovolaemic with a heart rate of 120 beats/minute, good quality pulses, and a CRT of 2 seconds
Comfortable on abdominal palpation
Mildly pyrexic at 39.5 degrees C
In poor body condition (score 3/9) with 4.5kg weight loss in a 4 week period (21% of bodyweight)
Initial Results
You pass your examination findings on to the vet who asks you to place an IV catheter, and collect samples for biochemistry, haematology, TLI, B12 and folate. These bloods reveal:
Low albumin levels (15g/L; reference range 23-40)
Low total protein levels (40g/L; reference range 52-82)
Low vitamin B12 levels (156ng/ml; reference range >275)
Low folate levels (1.2ug/L; reference 8.2-13.5)
Increased PCV (55%)
Increased neutrophils (21.55 x 10^9/L; reference range 2-12)
An abdominal ultrasound is performed later that day, which reveals generalised GI changes and slightly small adrenal glands. Gastrointestinal endoscopy and biopsies reveal lymphoplasmacytic enteritis (IBD) with lacteal dilation (lymphangiectasia). Bea is subsequently diagnosed with IBD and protein-losing enteropathy.
Bea’s Treatment
You start Bea on treatment for her PLE, including:
Dexamethasone
Maropitant
Ondansetron
Metoclopramide CRI
VBS Clay
Capromorelin (appetite stimulant)
Vitamin B12
Hartmann's/LRS solution (rate dependent on fluid output)
20mmol/L potassium chloride supplementation in her IV fluids
Amoxiclav IV (later switched to PO due to an adverse reaction)
Bea remains in hospital poorly responsive to supportive treatment. She is cardiovascularly stable, but has continued watery diarrhoea with leakage and sore skin around her back end. She also develops peripheral oedema secondary to her hypoalbumiaemia, and remains anorexic in hospital.
Bea’s Nursing Care
So you have Bea hospitalised, and it’s time to start thinking about her nursing! How would you manage her in the hospital? Here are some prompts for you to think about:
Nutritional status and appetite support
Hydration status and fluid balance
Toileting/eliminations and diarrhoea management
Grooming, skin and coat care
Vascular access
Management of peripheral oedema
Gastrointestinal motility, regurgitation and gastric volume
So what will we do for Bea?
Nutrition and Appetite Support
Nutrition is one of our top considerations for Bea. We need to get her albumin level up, and get some nutrition to those enterocytes.
Given her ongoing anorexia and weight loss, we’re going to need a feeding tube. In Bea’s case, because she’s regurgitating, a nasogastric tube would be a good option - since we can use this to aspirate her stomach contents and measure her gastric residual volumes.
This is exactly what we did. As her regurgitation improved and her gastric residual volumes decreased, we switched this to an oesophagostomy tube - given that she was going to need long-term nutritional support, and multiple oral medications. The main benefit of our O tube (as well as her not being as likely to pull this out - a favourite trick of hers with her NG tube!) was that we could send her home with this in, so her family could continue feeding her at home should her appetite decrease.
We also needed to consider what we feed. Given her diagnosis of protein-losing enteropathy, we ideally want Bea on a diet that is low in fat, and hypoallergenic (hydrolysed or a novel protein source). We tube fed her with a hydrolysed, low fat food beginning at 25% RER, and increasing gradually over the next 4 days.
Alongside this, we tempted Bea to eat, and continued her antiemetics and appetite stimulants. We prioritised lower fat foods, such as gastrointestinal low fat diets, hydrolysed low fat diets, and plain cooked chicken or white fish - measuring the calories intaken at each meal, then topping up with tube feeding as needed.
Hydration and Fluid Balance
With her chronic diarrhoea and ongoing vomiting and regurgitation, hydration was another important consideration for Bea.
Alongside this, she’s hypoalbuminaemic - causing a loss in her colloidal oncotic pressure, and fluid leakage leading to oedema.
We’re going to need to keep a close eye on her hydration status, weighing her regularly and monitoring her for signs of both dehydration and fluid overload.
We don’t want to push high rates of fluid, given that this could worsen her oedema - in her case, we measured her diarrhoea output (more on that in a second!) and ensured we were matching these ongoing losses through her fluids.
Regarding her albumin level, we could consider giving her an albumin transfusion (in the UK that’s human serum albumin, rather than canine albumin) - but it isn’t without risk, and so we opted to increase it through her nutrition, alongside managing her GI disease.
Toileting and Eliminations
Managing Bea’s diarrhoea was a huge nursing consideration. We placed a faecal Foley catheter and attached this to a collection system, keeping her clean and measuring the fluid lost through her ongoing diarrhoea.
These systems require careful management to avoid complications like rectal wall necrosis/perforation. Every 4 hours, we deflated the balloon, repositioned the catheter, and gently inflated it again, to avoid pressure necrosis from the inflated balloon staying in the same spot. A manometer syringe could also be used when inflating these, to measure the pressure placed on the rectal wall - a bit like we do for ET tube cuffs.
Bea also received high doses of steroid to manage her inflammatory enteropathy - and PUPD is a common side-effect of this. So regular toilet walks to manage her urination - and provide some leg-stretching opportunities and mental enrichment - were indicated. The regular walks also helped with her peripheral oedema, as we wanted to try and get her moving and shift that fluid.
Grooming, Skin and Coat Care
Bea had a tendency to try and remove her Faecal foley catheter at any opportunity. This, coupled with her ongoing (often leaking) watery diarrhoea and long hair was a recipe for disaster. She would often end up soiled, and had some sores around her back end despite regular bathing, tail wrapping and application of barrier cream.
This caused discomfort, which resulted in Bea then self-traumatising her back end, in turn making her skin more sore.
To manage this, we placed a large Elizabethan collar which was strictly kept on at all times. A wide margin of fur around her anus was clipped, to minimise soiling. Her tail was wrapped with padding applied under the vetwrap at the top, to avoid the vetwrap rubbing on her sore skin. The area was checked hourly and bathed as needed (with cold water to try and soothe the inflamed area, and avoiding shampoos that may cause further irritation or discomfort) before being dried thoroughly, and following this, barrier cream was applied liberally.
Vascular Access
Bea was hospitalised for a long time, required multiple CRIs, fluids and medications, and had relatively frequent sampling in hospital (bloods 2-3 times a week on average). That, coupled with her peripheral oedema, made IV catheters a real challenge.
In Bea’s case, her nurses advocated for a central venous catheter. This isn’t an ideal solution for her, as her protein-losing enteropathy makes her at a higher risk for thrombosis - but we reached a point where the alternative was no IV access, which was deemed more of a concern.
She was anaesthetised and a 7F CVC was placed in her right jugular vein (alongside the O tube which was placed under the same GA). This was managed carefully, following strict aseptic technique, and flushing regularly with 0.9% saline to prevent clots.
Managing Oedema
We performed regular physiotherapy with Bea to try and reduce her peripheral oedema. This included regular walking (which also boosted her morale and provided some environmental enrichment) alongside massage, passive range of motion and effleurage techniques. Bea also really enjoyed the extra TLC her physio sessions brought her - showing that actually, our time and attention itself is an important nursing consideration, especially for our long stay patients.
Gastrointestinal Motility and Regurgitation
Bea’s regurgitation and ileus was another important nursing consideration. If we couldn’t get those guts moving, we’d see her continue to have regurgitation - plus, we’d also be unable to get nutrition in, since any food would just sit in her stomach.
Alongside placing her NG tube and aspirating her stomach contents regularly, we also maintained her on several prokinetic medications - adding Cisapride to her metoclopramide, and keeping erythromycin and magnesium as backup options for their prokinetic effects.
When we aspirated her stomach, we were careful to return a portion of the content - because if we remove too much, we can cause acid-base imbalances (given that hydrogen and chloride is present in gastric acid). So we returned 10ml/kg, discarding the rest.
We began feeding her with small volumes of food (25% RER) as a trickle feed to see how she would tolerate this, and increased the volumes given according to her regurgitation and gastric residual volumes.
On top of this, we walked Bea regularly to try and get things moving as much as we could.
Other Considerations
As Bea was a long-stay patient, her family regularly came to visit her. This both provided mental enrichment for her and comforted her family, and helped encourage her to eat voluntarily.
We also barrier nursed Bea - we knew her diarrhoea was not infectious, but she was on immunosuppressive steroid doses (and midway through her hospitalisation, we added additional immunosuppressive agents). So protecting her from hospital-acquired infection was another important consideration.
Lastly, we also performed an ACTH stimulation test whilst Bea was hospitalised. This was an important consideration because we know Addison’s disease likes to pretend to be GI disease - and because, if Bea did have Addison’s, she would need very different management in hospital. Although this isn’t really a nursing consideration, it’s still important for us to know about - because we see so many GI cases, and often, an Addison’s will try and slip through the net with them!
So as you can see, Bea needed a LOT of nursing care. She wasn’t a particularly critical patient, but required very intensive nursing - giving us tons of opportunities to develop new skills, as well as make an enormous difference to her!
